Despite aggressive management, septic shock arising from Gram-negative sepsis continues to be a leading cause of death in both surgical and medical patients. Death in such patients usually results from cardiovascular collapse and/or multiple organ system failure. One of the main components of Gram-negative bacterial thought to play an integral role in causing septic shock is an outer wall constituent, endotoxin (LPS).
Endotoxins are high molecular weight complexes, associated with the outer membrane of Gram-negative bacteria that produce pyrogenic reactions upon intravenous administration. Endotoxin is shed from living bacteria and is also released into the environment when bacteria die and decompose.
Bacterial endotoxin is a complex consisting of lipid, carbohydrate and protein. It is characterized by an overall negative charge, heat stability and high molecular weight. Highly purified endotoxin does not contain protein, and is a lipopolysaccharide (LPS).
Bacterial endotoxins are known to have profound biological effects in animals and humans, and to cause severe medical problems when present. Symptoms include induction of high fever, activation of complement and cytokine cascade and hypotension. It is critical to avoid endotoxin contamination in any pharmaceutical product or medical device, which come into contact with body fluids. High endotoxin levels in sera due to bacterial diseases, such as septicemia, are not easily treated. Antibiotic treatment of the infection only kills the bacteria, leaving the endotoxin from their cell walls free to cause fever.
LPS is an important mediator in the pathogenesis of septic shock and is one of the major causes of death in intensive-care units in the United States. It has been observed that exposure to LPS during sepsis stimulates an immune response in monocytes and macrophages that results in a toxic cascade resulting in the production of TNF-xcex1 and other proinflammatory cytokines. Morrison and Ulevitch, Am. J. Pathol., 93:527 (1978). Endothelial damage in sepsis probably results from persistent and repetitive inflammatory insults. Bone, Annals Int. Med. 115:457 (1991).
Several proteins have been investigated for their ability to bind and neutralize LPS and the potential use in the septic shock treatment. Among the most extensively studied of the LPS-binding proteins is bactericidal/permeability-increasing protein (BPI), a basic protein found in the azurophilic granules of polymorphonuclear leukocytes. The BPI protein from human PMNs has potent bactericidal activity against a broad spectrum of Gram-negative bacteria. This antibacterial activity appears to be associated with the amino terminal region (amino acids residues 1-199) of the isolated human BPI protein. Recently it has been shown that the N-terminal fragment of BPI (rBPI25) neutralizes endotoxin activities and inhibits LPS-induced events in neutrophiles and macrophages. Helene et al., Infection and Immunity. 62:1185 (1994). In addition to its bactericidal effects, BPI has been shown to neutralize the toxic and cytokine-inducing effects of LPS to which it binds. Xoma Corporation is building a portfolio of therapeutic products based on BPI protein. The company""s lead BPI-derived product, Neuprex, is in clinical efficacy trials for four indications: [1] Meningococcemia, [2] Hemorrhagic trauma, [3] Partial hepatectomy, [4] Severe intro-abdominal infections. XOMA Corporation Jul. 30, 1996.
Lipopolysaccharide binding protein (LBP) is a 60 kD glycoprotein synthesized in the liver, which shows significant structural homology with BPI. Shumann et al. Disclose the amino acid sequences and encoding cDNA of both human and rabbit. Like BPI, LBP has a binding site for lipid A and binds to the LPS from rough and smooth form bacterial. Unlike BPI, LBP does not possess significant bactericidal activity, and it enhances (rather than inhibits) LPS-induced TNF production. Schumann et al., Science, 249:1429 (1990).
One of the normal host effector mechanisms for clearance of bacteria involves the binding to and subsequent phagocytosis by neutrophils and monocytes. As part of this process, bacteria are exposed to bactericidal and bacteriostatic factor, including oxygen radicals, lysosomal enzymes, lactoferrin and various cationic proteins. LBP opsonizes LPS-bearing particles and intact Gram-negative bacteria, mediating attachment of these LPB-coated particles to macrophages. Wright et al., J. Exp. Med. 170: 1231 (1989). The attachment appears to be through the CD14 receptor of monocytes, which bind complexes of LPS and LBP. Wright et al. Science 249: 1431 (1990). Interaction of CD14, which is present on the surface of polymorphonuclear leukocytes as well as monocytes, with LPS in the presence of LBP has been shown to increase the adhesive activity of neutrophils. Wright et al., J. Exp. Med. 173: 281 (1991), Worthen et al., J. Clin. Invest. 90: 2526 (1992). Thus, while BPI has been shown to be cytotoxic to bacteria and to inhibit proinflammatory cytokine production stimulated by bacteria, LBP promotes bacterial binding to and activation of monocytes through a CD14-dependent mechanism. Novel biologically active lipopolysaccharide binding protein (LBP) derivatives including LBP derivative hybrid proteins which are characterized by the ability to bind to and neutralize LPS and which lack the CD14-mediated immunostimulatory properties of holo-LBP. Gazzano-Santoro, WO 95/00641. Moreover, peptides corresponding to residues 91-108 of LBP protein were identified that specifically bound the lipid A with high affinity. The peptides inhibited binding of LPS to LBP, inhibited the chromogenic Limulus amebocyte lysate reaction, and blocked release of TNF following LPS challenge both in vitro and in vivo, Taylor24 et al., J. of Biol. Chem. 270: 17934, (19951.
Another LPS-binding proteins capable to bind and neutralize the endotoxin have been isolated from a horseshoe crab such as Limulus polyphemus and Tachypleus antilipopolysaccharide factor (TALF) isolated from Tachypleus tridentatus, Kloczewiak29 et al., J. Infect. Dis. 170: 1490-7 (1994). . The cells from their hemolymph (amebocytes) undergo a complex series of biochemical reactions resulting in clot formation, analogous to mammalian blood coagulation. This phenomenon has been exploited in the form of bioassays sensitive to very low endotoxin levels.
Currently, a bioassay of this type is the method of choice for monitoring pharmaceutical manufacturing and is termed Limulus Amebocyte Lysate (LAL). Wainwright et al., WO 92/20715 relates the invention to the pharmaceutical utility of the endotoxin binding/neutralizing protein and disclose the use of the endotoxin binding/neutralizing protein for an endotoxin assay. It is yet another object of the invention to provide pharmaceutical compositions capable of binding and neutralizing endotoxin in vivo and containing therein an endotoxin binding/neutralizing protein corresponding at least to part of the endotoxin binding and neutralizing domain of the endotoxin binding/neutralizing protein isolated from a horseshoe crab in accordance with the invention.
Limulus anti-LPS factor (LALF) have been investigated for use in sepsis. Warren et al., Infect.Immun. 60: 2506-2513 (1992) and Garcia25 et al., Crit. Care. Med. 22: 1211 [1994]. This protein is almost certain to suffer the disadvantages associated with other foreign proteins for human therapy, it is immunogenic and has only a shart half-life in circulation. These factors will reduce its clinical potential. None of these substances have been proven to be effective for the treatment of the serious conditions associated with Gram-negative infection in humans.
The solution to the above technical problem was achieved by providing substances, which relate to peptides, which bind tightly to LPS, and therefore have utility in the diagnosis and treatment of Gram-negative and other septic conditions. Battafaraono et al., synthesized three peptides from BPI, LALF, LBP (each 27 amino acid in length) of the proposed LPS-binding motif for these proteins. All small peptides derived from BPI, LALF and LBP retained significant endotoxin-neutralizing and bactericidal activity against many different gram-negative bacterial in vitro Battafaraono26 et al., Surgery 118: 318-24 [1995]. More recently, Fletcher et al., designed a novel peptide-IgG conjugate, CAP-18 (106-138)-IgG, it binds and neutralizes endotoxin and kills gram-negative bacteria. Fletcher27 et al., J. Infect. Dis. 175: 621-32 [1997].
Hoess et al., WO 95/05393 relates the invention to substances which bind with high affinity to endotoxin (lipopolysaccharide [LPS]), and which are useful for the prevention or treatment of, for example, Gram-negative and Gram-positive bacterial sepsis, and for the treatment of bacterial and fungal infections as well as for neutralizing effects associated with heparin. The substances are LPS-binding peptides comprising an LPS-binding domain. A peptide comprising the amino acids31-52 from Limulus anti-LPS factor (LALF) was disclosed.
The crystal structure of LALF reveals a simple tertiary fold, which has a striking shape and amphipathicity. A surface-extended loop in the LALF structure (loop of LALF or LALF-loop) has similar features to polymyxin B by being positively charged and amphipathic and having several exposed hydrophobic and aromatic residues. Furthermore, the loop of LALF is distinguished by an alternating series of positively charged and hydrophobic/aromatic residues that, by virtue of the extended xcex2-conformation, point in opposite directions, and a single pair of positive charges, that, because of the xcex2-turn conformation, point in the same direction and maintain the amphipathicity. The loop contains no negatively charged amino acids. Hoess had described the minimal requirements of rLALF for endotoxin and lipid A with linear 10-mer peptides. Cyclic peptides, however, bind lipid A and endotoxin with high affinity, presumably by mimicking the three dimensional characteristics of the exposed hairpin loop, Ried28 et al., J. Biol. Chem. 271: 28120-7 [1996]. The cyclic peptide LALF36-47 is able to blocks TNF induction after endotoxin challenge in mice. Most recently have been described that Limulus antilipopolysaccharide factor (LALF) neutralize bacterial endotoxin and protect mice from LPS lethality even when LALF is administered long after the onset of continuous endotoxemia, Roth31 RI. Su D H. Child A H. Wainwright N R and Levin J. Journal of Infectious Diseases. 177 (2): 388-394, 1998.
A similar amphipathic loop exists in three other proteins which bind LPS: rabbit and human lipopolysaccharide-binding protein (LBP) and human bactericidal/permeability-increasing protein (BPI). Inspection of the LBP and BPI sequences reveals a similar pattern of alternating residues that could produce an amphipathic loop.
However, these inventions do not reveal anything about the antiviral effect and/or activation of monocytes of either the endotoxin binding/neutralizing protein from Limulus polyphemus or the peptide comprising the amino acids31-52 (SEQ ID NO: 1) from the protein. The use or therapeutic effectiveness in sepsis and infectious diseases are related with the LPS-binding. Furthermore, none of the references disclose the use of the peptide31-52 (SEQ ID NO: 1) from Limulus anti-LPS factor for an antiviral treatment or to enhance the immune response.
It is known that viruses are small infectious agents that contain only one type of nucleic acid in its genome (RNA or DNA), generally as a sole molecule. Viruses replicate only in living cells and in man they may produce different diseases.
A. Generalized diseases where the virus is disseminated throughout the body as in small pox, yellow fever, dengue, etc.
B. Diseases of the nervous system as in poliomyelitis, aseptic meningitis caused by the intestinal viruses (polio, coxsackie), rabies, encephalitis transmitted by arthropods, etc.
C. Diseases of the skin or mucose: Herpes simplex, type I (usually of the mouth) and type II (usually genital).
D. Ocular diseases: Conjunctivitis due to adenovirus, conjunctivitis due to the Newcastle virus, epidermal hemorrhagic conjunctivitis.
E. Diseases of the liver: Type A Hepatitis (infectious hepatitis), type B hepatitis (hepatitis through the serum), etc.
Given that the viruses are necessarily intracellular parasites, the antiviral agents should be capable of selectively inhibiting the viral functions without damaging the host. There are several compounds that inhibit the virus in a specific way without affecting cellular metabolism, for example the amantadine, a synthetic amine that inhibits the virus A of the influenza; metisazone, an inhibitor of many pox viruses, the trifluorotimidine has been used with success in the treatment of lesions of the cornea due to the Herpes simplex virus. Many of these agents are acting as antimetabolites have the handicap that they are toxic to man.
Also tested because of their antiviral capacity and immune system stimulating ability in animals and man are compounds such as Levamisol and Isoprinosine, these agents are not antimetabolites, but stimulators of cellular immunity.
The interferons, a kind of protein discovered in 1957, capable of inhibiting viral replication, are produced by animals and man, as well as by cultured cells, as a response to viral infection or some other inductor. Interferon is more effective as an antiviral substance in the cells of the same species. In contrast, the interferon activity is not specific for a certain virus. The interferon produced as a response to a virus or to another inductor, effectively inhibits the replication of a wide variety of viruses. When the interferon is added to the cells before the infection take place, there is a notable inhibition of viral replication, while the cell function remain normal.
Viral infections in man may also be associated with complications during serious surgical operations as in gastrointestinal surgery, or in patients having a high risk of infection at the site of the operation as in cardiovascular surgery.
In aseptic surgical operations such as abdominal or cardiovascular surgery, the so-called post-operational acute phase reaction is characterized by a deterioration of the phagocytic function, a reduction of the lymphocyte response to polyclonal activators and an altered function of B cells (D. Berger, Journal of Endotoxin Research, Vol. 4 No. 1 (1997). This phase is characterized by an immunological dysfunction of the patient. The pneumonia produced by the cytomegalovirus (CMV) is more important in persons having an immune deficiency, such as patients treated with immuno-suppressors as a result of an organ transplant or a malignant process, as well as persons with natural immunologic deficiencies such as hypogammaglobulinemia and with weakening chronical processes, for which reason a pneumonia produced by CMV may be a complication in any patient with a decreased immunological capacity. Pneumonias of viral origin, do not respond to antimicrobial treatment. The pneumonia produced by the grippe virus generally affects elderly persons that are immunologically depressed due to underlying non-infectious diseases, as for example, lung, cardiovascular or kidney diseases. In all these cases it would be very useful to count on an agent with antiviral and/or immune system stimulating properties.
This invention is particularly important in the medical field. The effectiveness of the peptide disclosed herein is related to the antiviral and antibacterial effects, furthermore to activate the immune system and protect the host against bacterial or viral infectious. Thus, the peptide31-52 (SEQ ID NO: 1) from Limulus anti-LPS factor is useful in the treatment and/or prophylaxis of both viral and bacterial infectious diseases, patients who are at a heightened risk of infection due to imminent surgery, injury, illness, or other such condition which deleteriously affects the immune system. The peptide is also useful in the treatment of immumosuppressed patients. Take together, the peptide of this invention can be considered as a new immunomodulatory agent of the immune system with a broad spectrum for the treatment of infectious diseases.
The invention relates to a peptide comprising the amino acids31-52 (SEQ ID NO: 1) from Limulus anti-LPS factor protein isolate from a horseshoe crab such as Limulus polyphemus which enhance a host""s immune defense mechanisms to infection but not induce an inflammatory response.
This peptide has been shown to have an antiviral effect to protect the cells against the viral infection in vitro assay. Furthermore, supernatant from human mononuclear cells incubated with the peptide contain certain soluble mediator(s), such as IFN-xcex3, able to confer protection to the cells Hep-2 against future viral infections. Another hand, this peptide protects against a direct infection in vivo. These advantageous properties make the peptide of this invention useful in the prevention and treatment of infections because they selectively activate only those components of the immune system responsible for the initial response to infection, without stimulating the release of certain biochemical mediators that can cause adverse side effects. The peptide also lacks the toxicity common to many immunomodulators.
The peptide of this invention is synthesized using a solid phase procedure. Crude peptide was extracted with a 30% acetic acid solution in water, lyophilized and then purified by RP-HPLC. Molecular mass of purified peptide was verified using a JEOL JMS-HX110HF two sector mass spectrometer equipped with a FAB gun. The resulting preparation is non-antigenic, non-pyrogenic and is pharmaceutically acceptable for administration to animals and humans.
The peptide comprising the amino acids31-52 (SEQ ID NO: 1) from Limulus anti-LPS factor protein of this invention can be used as safe, effective, therapeutic and/or prophylactic agents, either alone or as adjuvants, to enhance the immune response in humans and animals. The peptide comprising the amino acids sequences disclosed herein selectively activate only those components that are responsible for the initial response to infection caused both bacterial or viral pathogens, without stimulating or priming the immune system to release certain biochemical mediators (e.g., TNF, IL-1) that can cause adverse side effects. As such, the present peptide can be used to prevent or treat infectious diseases caused both bacterial or viral pathogens in malnourished patients, patients undergoing surgery and bone marrow transplants, patients undergoing chemotherapy or radiotherapy, neutropenic patients, HIV-infected patients, trauma patients, bum patients, patients with chronic or resistant infections, all of who may have weakened immune systems. An immunocompromised individual is generally defined as a person who exhibits an attenuated or reduced ability to mount a normal cellular and/or humoral defense to challenge by infectious agents, e.g., viruses, bacteria, fungi and protozoa. A protein malnourished individual is generally defined as a person who has a serum albumin level of less than about 3.2 grams per deciliter (g/dl) and/or unintentional weight loss of greater than 10% of usual body weight.
More particularly, the method of the invention can be used to therapeutically or prophylactically treat animals or human who are at a heightened risk of infection due to imminent surgery, injury, illness, radiation or chemotherapy, or other such condition which deleteriously affects the immune system. The method is useful to treat patients who have a disease or disorder which causes the normal metabolic immune response to be reduced or depressed, such as HIV infection (AIDS). For example, the method can be used to pre-initiate the metabolic immune response in patients who are undergoing chemotherapy or radiation therapy, or who are at a heightened risk for developing secondary infections or post-operative complications because of a diseases, disorder or treatment resulting in a reduced ability to mobilize the body""s normal metabolic responses to infection. Treatment with the peptide has been shown to be particularly effective in mobilizing the host""s normal immune defenses, thereby engendering a measure of protection from infection in the treated host. It may be used in elderly persons, immunologically depressed by non infectious diseases as cardiovascular or chronical diseases. It is known that these persons are susceptible to viral pneumonia e.g. the grippe virus. It may also be effective in the treatment of pneumonia due cytomegalovirus (CMV), which are more important every day in persons having immunity deficiency, e.g. persons treated with immuno-suppressors as a result of an organ transplant. The treatment with this peptide could be particularly attractive in strengthening the immune response in patients with trauma or it may be administered during the so called post-operational acute phase, where viral infections are generally associated producing severe consequences, where the patients do not respond to the antimicrobial treatments. Both in persons with traumas, as during the acute post-operational phase, there is a deterioration of the immune response given mainly by a decrease of the activity of the macrophages and their inability to respond adequately during an infection (Berger et al., Clin. Chem. Acta. 1995, Vol. 239: 121-130. Therefore, the agents that stimulate the function of the macrophages, as the main mediators of the immune response, would be of great therapeutic and prophylactic value in infectious diseases of viral or bacterial origin. The treatment with the peptide has demonstrated that it is particularly effective in mobilizing the normal immune defenses of the host, producing an increase in the protection of the host to the infection.
In another embodiment the peptide of the invention can be administrate to patients"" undergoing xe2x80x9cimmunoparalysisxe2x80x9d (Randow et al. , J. Exp. Med. 1995, Vol. 181: 1887-1892.), defined as the reduction of the monocytic MHC class II, impaired monocytic antigen-presenting activity and their diminished ability to produce inflammatory cytokines. This phenomenon is called Compensatory Anti-inflammatory Responses Syndrome (CARS). During the late hypoinflammatory phase in sepsis monocytic stimulation is useful because restitute the deficient phenotype and function of monocytes from patients with xe2x80x9cimmunoparalysisxe2x80x9d.
The present peptide is generally administered to an animal or human in an amount sufficient to produce immune system enhancement. The mode of administration of the peptide can be oral, enteral, parenteral, intravenous, subcutaneous, intraperitoneal, or intramuscular. The form in which the composition will be administered (e.g., tablet, capsule, solution, emulsion) will depend upon the route by which it is administered. The quantity of the composition to be administered will be determined on an individual basis, and will be based at least in part on consideration of the severity of infection or injury in the patient, the patient""s conditions or overall health, the patient""s weight and the time available before surgery, chemotherapy or other high-risk treatment. In general, a single dose will preferably contain approximately 5 mg to 10 mg of peptide per kilogram of body weight. In general, the composition of the present invention can be administrated to an individual periodically as necessary to stimulate the individual""s immune response.
An individual skilled in the medical arts will be able to determined the length of time during which the composition is administrated and the dosage, depending upon the physical condition of the patient and the disease or disorder being treated. As stated above, the composition may also be used as a preventative treatment to pre-initiate the normal metabolic defenses, which the body mobilizes against infections.
The peptide can be used for the prevention and treatment of infections caused by a broad spectrum of bacterial, fungal, viral and protozoan pathogens. The prophylactic administration of peptide to a person undergoing surgery, either preoperatively, intraoperatively and/or post-operatively, will reduce the incidence and severity of post-operative infections in both normal and high-risk patients. For example, in patients undergoing surgical procedures that are classified as contaminated or potentially contaminated (e.g., gastrointestinal surgery, hysterectomy, cesarean section, transurethral prostatectomy) and in patients in whom infection at the operative site would present a serious risk (e.g., prosthetic arthroplasty, cardiovascular surgery), concurrent initial therapy with an appropriate antibacterial agent and the present peptide preparation will reduce the incidence and severity of infectious complications.
In patients who are immunosuppressed, not only by disease (e.g., cancer, AIDS) but by courses of chemotherapy and/or radiotherapy, the prophylactic administration of the peptide preparation will be reduce the incidence of infections caused by a broad spectrum of opportunistic pathogens including many unusual bacteria, fungi and viruses.
In high risk patients (e.g., over age 65, diabetics, patients having cancer, malnutrition, renal disease, emphysema, dehydration, restricted mobility, etc.) hospitalization frequently is associated with a high incidence of serious nosocomial infection. Treatment with this peptide preparation may be started empirically before characterization, use of respirators, drainage tubes, intensive care units, prolonged hospitalizations, etc. to help prevent the infections that are commonly associated with these procedures. Concurrent therapy with antimicrobial agents and the peptide preparation is indicated for the treatment of chronic, severe, refractory, complex and difficult to treat infections.
The compositions administered in the method of the present invention can optionally include other components, in addition to the peptide. The other components that can be included in a particular composition are determined primarily by the manner in which the composition is to be administered. For example, a composition to be administered orally in tablet form can include, in addition to peptide, a filler (e g., lactose) a binder (e.g., carboxymethyl cellulose, gum arabic, gelatin), an adjuvant, a flavoring agent, a coloring agent and a coating material (e.g., wax or plasticizer). A composition to be administered in liquid form can include peptide and, optionally, an emulsifying agent, a flavoring agent and/or a coloring agent. A composition for parenteral administration can be mixed, dissolved or emulsified in water, sterile saline, PBS, dextrose or other biologically acceptable carrier. A composition for topical administration can be formulated into a gel, ointment, lotion, cream or other form in which the composition is capable of coating the side to be treated, e.g., wound site.
Compositions comprising peptide preparation can be administered topically to a wound site to stimulated and enhance wound healing and repair. Wounds due to ulcers, acne, viral infections, fungal infections or periodontal disease, among other, can be treated according to the methods of this invention to accelerate the healing process. Alternatively, peptide preparation can be injected into wound or afflicted area. In addition to wound repair, the composition can be used to treat infection associated therewith or the causative agents that result in the wound. A composition for topical administration can be formulated into a gel, ointment, lotion, cream or other form in which the composition is capable of coating the site to be treated, e.g., wound site. A typical dosage for wound will be from about 5 mg to about 10 mg.
In another embodiment this invention relates to hybrid polypeptides containing the mentioned peptide sequences wherein the preferred peptide sequences constitutes the N-terminus or the C-termninus of larger polypeptide chains in a way that maintain its ability to enhance the immune response and confers this ability to the hybrid polypeptide. One preferred hybrid polypeptide comprises a fusion of any of the preferred peptides and heavy chain regions of IgG.
This invention also relates to scaffold proteins that properly exposed of the mentioned peptide sequences in such a way that maintains or enhances their ability to enhance the immune response and confers this ability to the hybrid polypeptide. The term xe2x80x9cscaffold proteinsxe2x80x9d as used herein refers to hybrid polypeptides, which include within their polypeptide chain one or more of the selected LALF sequences in a such a way that the inserted segment forms an exposed loop in the structure of the fused protein, or polypeptide.
Peptide half life in vivo and other pharmacological parameters could be improved with hybrid and scaffold polypeptides and proteins including the preferred peptide sequence. Also DNA sequences encoding the peptides, or encoding hybrid or scaffold proteins containing the peptide sequence could be inserted in proper vectors to be expressed in vivo for therapeutic purposes along with appropriated carriers, diluents, adjuvant or stabilizing solutions or chemicals.
The novel immunological activity from Limulus anti-LPS factor peptide disclosed herein enhances the non-specific defenses of mammalian mononuclear cells and significantly increases their ability to respond to an infectious challenge. In another hand, it does not result in increased body temperatures (e.g., fever) as has been reported with many non-specific stimulants of those defenses. This critical advantage of peptide preparation may lie in the natural profile of responses it mediates in white blood cells. It has been shown that the effect of the present invention selectively activates immune responses but does not directly stimulate or prime cytokine (e g., TNF) release from mononuclear cells, thus distinguishing from other immunostimulants.